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Bush Proposal Shifts Resources to Rural AIDS, Medical Care

Hardest-Hit Cities, Essential Services Would Lose Funding

August 24, 2005

Chicago -- The Bush administration unveiled a proposal today to shift billions of dollars for HIV/AIDS-related services away from hard-hit urban centers in order to expand medical care in poor and rural parts of the country with increasing rates of HIV.

The announcement, made today by Health Secretary Michael Leavitt, is the clearest indication yet of the administration's position to address the nation's expanding HIV/AIDS crisis without committing new discretionary federal funds.

Secretary Leavitt's recommendations are expected to shape legislation being prepared to extend the Ryan White CARE Act -- the landmark HIV/AIDS relief program first created in 1990 and reauthorized by Congress in 1996 and 2000. The current authorization expires on September 30, 2005.

The proposal would decrease overall funding to the 51 hardest-hit cities that receive Title I grants by reducing their state's Title II allocations, a share of which also supports services in urban areas. By limiting CARE Act funding for states with large urban centers, a greater share of available resources would go to states with less dense epidemics, especially in southern states where HIV/AIDS has increased rapidly in recent years.

Requiring that no less than 75% of CARE Act dollars support medical care, the proposal would limit CARE Act funding for essential services such as transportation, housing, food, and legal assistance. Another provision would allow the U.S. Department of Health and Human Services to reallocate unspent Title I and II funds to cash-strapped AIDS Drug Assistance Programs (ADAP) across the nation.

Furthermore, local community planning groups would no longer be required to prioritize funding by service categories or assist in shaping the local service system. Under the proposal, these groups would become advisory to the municipal grantee -- typically the city or county health department -- which would gain greater autonomy in determining how local CARE Act dollars are to be spent.

Overview of Recommendations

Focus on Medical Care

  • Legislation would define "a set of core medical services," which would include primary medical care and assistance obtaining medications. Beyond outpatient medical care and medication assistance, it is not clear what services the administration will classify as core.

  • No less than 75% of funding for Titles I through IV must support "core" services.

  • The U.S. Department of Health & Human Services (HHS) would develop a list of "core medications," which would be prioritized through state ADAPs.

  • HHS would reallocate any unspent Title I and II funds to struggling ADAPs, including those with waiting lists.

Focus on Rural

  • A new distribution formula for Title II funding would be based solely on a state's HIV/AIDS cases reported in non-Title I jurisdictions. In a level or decreased funding scenario -- as has been the case over the past five years -- the result will be smaller grants to states with one or more Title I Eligible Metropolitan Areas (EMAs), and slightly larger grants to states that do not receive Title I funding.

  • Legislation would eliminate a provision, called the "hold harmless" provision, which limits the amount of funding a jurisdiction may lose over a five year period as a result of shifts in the HIV/AIDS population.

Focus on Populations With Greatest Needs

  • HHS would develop a "severity of need" index to use in Title I and II formula distributions. The index would factor such criteria as levels of poverty, other available public and private resources, and HIV incidence.

Prevention Focus

  • Legislation would encourage CARE Act grantees to "adopt various important HIV prevention strategies, such as routine opt-out HIV testing, contact tracing, and the recommendations of the CDC Advancing HIV Prevention Initiative." It is not clear whether the administration expects CARE Act funding to support expanded HIV testing activities, given the program's historic focus on care services.

Expanded Reporting and Accountability Requirements

  • The proposal would require grantees to expand efforts to document that no other funding sources, public or private, are available to pay for services provided to CARE Act recipients -- the so-called "payer of last resort" provision. Details about how these new requirements would be implemented and enforced were not made available.

  • The proposal would keep in place a provision of the 2000 reauthorization to include state-based HIV surveillance data as a factor in funding distribution formulas beginning in fiscal year 2007. CDC has refused to integrate into its national projections data provided by states, such as Illinois, that collect HIV surveillance data by alphanumeric code, instead of name. The proposal does not address this concern.

  • The proposal calls for more local, state, and federal coordination, and greater emphasize on system- and client-level reporting mechanisms to evaluate program performance. No details were made available.


The AIDS Foundation of Chicago (AFC) supports access to comprehensive services for all people living with HIV/AIDS. Inadequate access to an array of essential services -- including but not limited to drug therapies and HIV specialty medical care -- puts people with HIV/AIDS at risk of dangerous health complications. Failure to adequately respond to the HIV/AIDS crisis in the U.S. is costly and dangerous to the public health, and undermines efforts to promote voluntary HIV testing.

Without a commitment to adequate funding for CARE Act services, geographic inequities will persist in the delivery of HIV/AIDS services. Unfortunately, the proposal advanced today by the Bush administration would shift inequities from rural and poor states to the inner cities. Improving HIV care in rural America -- an important goal -- should not come at the expense of poor people with HIV/AIDS who live in urban centers, including Chicago. According to the CAEAR Coalition , more than 70% of people with HIV/AIDS in the U.S. live in a metropolitan area served by Title I. Moreover, rural residents in states with Title I funding will likely have their care disrupted by the administration's proposal. Shifts in resources will mean less funding for rural care in these states. It will also mean that essential services, such as transportation to medical and social service appointments, will be reduced.

AFC agrees that medical care should be prioritized for those in greatest need but does not believe the proposal will realize this principle. Expanding medical care should not come at the expense of enabling services that have proved effective at helping vulnerable populations gain access to and stay in care. Enabling services such as housing, substance abuse treatment, case management, legal services, and nutritional assistance, among others, are cost-effective ways to improve the quality of life of low-income people with HIV/AIDS and sustain engagement in healthcare services. Diminishing funding for these essential services will prove counterproductive.

AFC also opposes plans to make stakeholder input in the planning and prioritization of Title I services optional. The engagement of community stakeholders, especially people living with HIV/AIDS, has helped ensure that service systems are responsive to community needs.

AFC urges members of Congress to draft legislation that responds to the needs of people with HIV/AIDS across the U.S. and retains funding for all essential services.

Learn More

AFC has compiled online the policy position statements of various regional and national AIDS advocacy groups as well as other relevant documents, including the administration's proposal. Learn more at AFC's CARE Act Action Center at

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This article was provided by AIDS Foundation of Chicago.
See Also
More Policy Positions on the 2005 Reauthorization of the Ryan White CARE Act